Basic Information
| Provider Information | |||||||||
| NPI: | 1023001542 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SORCE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 259 E ERIE ST | ||||||||
| Address2: | STE 2230 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129266000 | ||||||||
| FaxNumber: | 3129268267 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 E ERIE ST | ||||||||
| Address2: | STE 2230 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129266000 | ||||||||
| FaxNumber: | 3129268267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 05/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036109735 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036109735 | 05 | IL | MEDICAID |